Real Hurdle for Alexander-Murray Bill is the House

President's view of bill called irrelevant

WASHINGTON -- A bill that aims to stabilize the individual health insurance market and lower premiums is gaining traction in Congress despite President Trump's lack of support.

Several policy scholars told MedPage Today that the Senate will probably pass the bill but whether it can win enough votes in the more conservative House is less certain.

On Tuesday, the chairman of the Senate Health, Education, Labor and Pensions Committee, Lamar Alexander (R-Tenn.), and Ranking Member Patty Murray (D-Wash.) said they had reached a bipartisan agreement to shore up the shaky individual insurance market on Tuesday.

By Thursday, the bill's co-authors had released a draft bill and announced the support of 24 senators including 12 Republicans, counting Alexander. Senators Lindsey Graham (R-S.C.) and Bill Cassidy, MD (R-La.), authors of the most recent repeal-and-replace efforts, were also cosponsors.

"Our agreement permanently amends the Affordable Care Act to give new flexibility for states to create insurance policies that have a larger variety and lower costs and it continues the cost-sharing reduction payments during 2018 and 2019," Alexander said in a press release on Thursday.

Alexander told reporters he'd received an encouraging phone call from the president about the bill on Wednesday morning, according to The Hill.

However, Trump panned the idea of funding cost-sharing reduction payments, a core provision of the bill, calling them "bailouts to insurance companies" in a speech Tuesday night, and again Wednesday on Twitter.

Arguably, the main reason to pass a "bipartisan fix" of Obamacare is to restore the CSR payments, government subsidies that help insurers minimize low-income enrollees' out-of-pocket costs. These are the subsidies that Trump canceled a week ago. They're at the center of a lawsuit brought by the Republican House under President Obama, over whether the monies had been legally appropriated by Congress. (See SCOTUSBlog for more details.)

One lobbyist and attorney said what Trump thinks of the bill is irrelevant.

"I think if they pass something in both houses, he'll sign it and then he'll take the credit for it," said Julius Hobson Jr., JD, senior policy advisor for Polsinelli, a law firm based here and an adjunct professor at the Graduate School of Political Management at George Washington University.

Sixty votes are needed for a bill to pass the Senate through regular order.

"With 12 Republicans and all of the Democrats, you're there," he said.

Sen. Chuck Schumer (D-N.Y.) has in fact said he believes every Democrat will support the bill, according to The Washington Examiner; in fact Schumer is calling for an immediate vote.

Sally Pipes, president and CEO of the Pacific Research Institute, a conservative San Francisco-based think-tank, said she's "not a fan" of the bill and agrees with the administration's decision to yank the CSR payments.

"If Congress can pass a bill to make them legal, then that's all fine," she said. "[But] it makes me nervous that the longer they continue them, the harder it will be to get rid of them."

The bill also restores funding for navigators and marketing, which Pipes said is not money well spent.

"I think the Obama administration spent a fortune on ads using movie stars and sports heroes," with unimpressive results.

"The question is, is the House going to keep holding out for a complete repeal and replace as opposed to a stabilization," said Marianne Udow-Phillips, PhD.

She said Graham, Cassidy and other conservatives may push the bill to the right, by stripping "guardrails" in the waivers that allow states to redesign their exchanges. That could make it more palatable to House Republicans, but could lose Democrats in the process.

As a stand-alone bill, Joe Antos, PhD, of the conservative American Enterprise Institute, said the bill has "zero chance" of passing both houses, but predicted the CSR payments will be restored for 2018 by packaging the authorization into other legislation. Continuation into 2019 may be more difficult, he said.

Antos said he couldn't see a path for the bulk of the navigator funding to be renewed, though some might be. He said a better strategy would be to include funding for insurance agents who are legally authorized to sign people up.

Time is growing short: the 2018 enrollment period opens Nov. 1. It won't be easy for insurers to refile rates and the system of rebates the senators have proposed is still hazy.

"I think the critical mass comes when open enrollment starts and the consumers are looking on line and they're going 'Holy you know what, I can't afford that'" Hobson said.

"It's hard to unscramble eggs," said Tim Jost, JD, an emeritus professor at the Washington and Lee University School of Law, who said all of this could have been avoided if a bill had been passed weeks ago.

"What the Congress's inability to recognize and deal with this issue and the president's absolute capriciousness has resulted in is a big mess, which is going to be hard to straighten out. If [the current bill] doesn't pass then we've just got a bunch of people in this country that will not be able to afford health insurance next year and ... a lot of them look like Trump voters."

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